Discover Portal

NIHR Signal People with osteoarthritis can benefit from exercise but may harbour myths about safety

Programmes that show people with osteoarthritis how to exercise safely may slightly improve pain scores, self-belief and social function, but participants also report the myth that discomfort while exercising indicates on-going harm.

The review combines evidence from 21 randomised controlled trials evaluating exercise in hip or knee osteoarthritis with 12 studies where people receiving the intervention were interviewed about the impact of exercise on their disease. Participants were men and women aged older than 45 years.

Analysis of the randomised trials provides moderate- to low-quality evidence that exercise slightly improved pain and function and gave small improvements in depression, social function and people’s belief in their physical capability.

Patient interviews highlight a common misconception that exercise can do more harm than good, and the important role healthcare professionals play in challenging these beliefs. Programmes that include clear, tailored instruction and provide opportunities to participate in supervised or group exercise may improve exercise uptake in people with hip and/or knee osteoarthritis.

Share your views on the research.

Why was this study needed?

Osteoarthritis is the most common form of joint disease, affecting at least eight million people in the UK. It can affect any joint, but it most commonly affects the knees, hips, neck and back, toes and fingers.

Exercise is recommended by NICE to reduce joint pain and improve mobility in people with osteoarthritis, but some studies have shown that exercise has additional benefits. It can also boost emotional well-being and lead to greater self-reliance, reduced disability and helplessness.

As there is no summary of the evidence to link physical, emotional and behavioural effects of osteoarthritis, and the potential of exercise to address these, the researchers reviewed evidence on the impact of exercise on people's pain, physical and emotional wellbeing, and aimed to determine the most effective ways to deliver exercise in this population.

What did this study do?

This study identified 21 randomised controlled trials (2,372 people) evaluating the effects of exercise on physical and mental health of men and women aged over 45 with hip and/or knee osteoarthritis. These were conducted in high-income countries including Europe. It also included a synthesis of qualitative evidence from patient interviews (12 studies, 197 participants). This research included studies that had asked about their perceptions of exercise and effects on pain and wellbeing alongside an exercise intervention.

The trials were differed by the population and participants examined. The trials also varied by the type, setting and time period of the exercise intervention. Most interventions (15 studies) were delivered by trained professionals who were either fitness/exercise instructors or physiotherapists. The variations in study characteristics made it hard for the researchers to draw clear general conclusions. Overall risk of bias in the trials was low, but because people knew they were taking part in exercise, this may have increased any perceived benefits.

What did it find?

Exercise reduced pain by 6% (95% confidence interval [CI] -9 to -4%; 9 studies, 1,058 participants, moderate quality). This equated to a reduction in pain score from 6.5 to 5.3 on a scale of 0 to 20. There was no difference in physical function (absolute reduction of 5.6%; 95% CI ‑7.6% to 2.0%; 13 studies, 1,599 participants, moderate quality).

Social function increased by 7.9% (95% CI 4.1 to 11.6; 5 studies, 576 participants, low quality). This equated to an improvement in social function score from 73.6 to 81.5 on a scale of 0 to100.

Interviews with participants found that pain, joint stiffness, tiredness, other illnesses and people's views of their physical fitness restricted the type and amount of exercise they felt able to do. Pain during exercise was also often thought to be causing additional joint damage, so people avoided activity for fear of causing more harm.

Participants also said that clear instructions from healthcare professionals outlining exactly what exercises to do, what to avoid, and what they might experience during the exercise helped to reassure them that exercise is safe and beneficial. Most interviewees thought that rehabilitation programmes that included a way to participate in exercise had physical, emotional and social benefits. Providing exercise recommendations that are tailored to individual preferences, abilities and needs was also important.

What does current guidance say on this issue?

The 2014 NICE guideline on osteoarthritis recommends exercise, irrespective of age, other conditions, pain severity or disability. This should include local muscle strengthening and general aerobic fitness. Stretching and manipulation is also recommended for hip osteoarthritis.

It is not specified whether exercise should be provided by the NHS or whether the healthcare professional should advise and encourage people to exercise independently. It does recommend that clinicians judge how best to ensure participation, depending on individual needs, circumstances and self-motivation, and the availability of local facilities.

Wider evidence on physiotherapy for musculoskeletal health and wellbeing was published by NIHR Dissemination Centre in July 2018.

What are the implications?

Overall this review adds evidence from patient interviews that could help healthcare professionals to encourage more effective uptake of exercise in this group. It reinforces existing evidence about the benefits of exercise for people with arthritis with slight improvements in pain and function, indicating how these benefits could be maximised.

Specific suggestions are that rehabilitation programmes could educate people about the causes and potential disease course of osteoarthritis, challenging the belief that exercise causes harm and reassuring people that it is safe and beneficial. The researchers suggest that advice is tailored to each individual patient, managing expectations about the ways in which exercise might improve or worsen their symptoms or leave pain and mobility unchanged.

Physiotherapists already have a role in offering personalised advice and encouragement and this review provides further evidence for them.

Why was this study needed?

Osteoarthritis is the most common form of joint disease, affecting at least eight million people in the UK. It can affect any joint, but it most commonly affects the knees, hips, neck and back, toes and fingers.

Exercise is recommended by NICE to reduce joint pain and improve mobility in people with osteoarthritis, but some studies have shown that exercise has additional benefits. It can also boost emotional well-being and lead to greater self-reliance, reduced disability and helplessness.

As there is no summary of the evidence to link physical, emotional and behavioural effects of osteoarthritis, and the potential of exercise to address these, the researchers reviewed evidence on the impact of exercise on people's pain, physical and emotional wellbeing, and aimed to determine the most effective ways to deliver exercise in this population.

What did this study do?

This study identified 21 randomised controlled trials (2,372 people) evaluating the effects of exercise on physical and mental health of men and women aged over 45 with hip and/or knee osteoarthritis. These were conducted in high-income countries including Europe. It also included a synthesis of qualitative evidence from patient interviews (12 studies, 197 participants). This research included studies that had asked about their perceptions of exercise and effects on pain and wellbeing alongside an exercise intervention.

The trials were differed by the population and participants examined. The trials also varied by the type, setting and time period of the exercise intervention. Most interventions (15 studies) were delivered by trained professionals who were either fitness/exercise instructors or physiotherapists. The variations in study characteristics made it hard for the researchers to draw clear general conclusions. Overall risk of bias in the trials was low, but because people knew they were taking part in exercise, this may have increased any perceived benefits.

What did it find?

Exercise reduced pain by 6% (95% confidence interval [CI] -9 to -4%; 9 studies, 1,058 participants, moderate quality). This equated to a reduction in pain score from 6.5 to 5.3 on a scale of 0 to 20. There was no difference in physical function (absolute reduction of 5.6%; 95% CI ‑7.6% to 2.0%; 13 studies, 1,599 participants, moderate quality).

Social function increased by 7.9% (95% CI 4.1 to 11.6; 5 studies, 576 participants, low quality). This equated to an improvement in social function score from 73.6 to 81.5 on a scale of 0 to100.

Interviews with participants found that pain, joint stiffness, tiredness, other illnesses and people's views of their physical fitness restricted the type and amount of exercise they felt able to do. Pain during exercise was also often thought to be causing additional joint damage, so people avoided activity for fear of causing more harm.

Participants also said that clear instructions from healthcare professionals outlining exactly what exercises to do, what to avoid, and what they might experience during the exercise helped to reassure them that exercise is safe and beneficial. Most interviewees thought that rehabilitation programmes that included a way to participate in exercise had physical, emotional and social benefits. Providing exercise recommendations that are tailored to individual preferences, abilities and needs was also important.

What does current guidance say on this issue?

The 2014 NICE guideline on osteoarthritis recommends exercise, irrespective of age, other conditions, pain severity or disability. This should include local muscle strengthening and general aerobic fitness. Stretching and manipulation is also recommended for hip osteoarthritis.

It is not specified whether exercise should be provided by the NHS or whether the healthcare professional should advise and encourage people to exercise independently. It does recommend that clinicians judge how best to ensure participation, depending on individual needs, circumstances and self-motivation, and the availability of local facilities.

Wider evidence on physiotherapy for musculoskeletal health and wellbeing was published by NIHR Dissemination Centre in July 2018.

What are the implications?

Overall this review adds evidence from patient interviews that could help healthcare professionals to encourage more effective uptake of exercise in this group. It reinforces existing evidence about the benefits of exercise for people with arthritis with slight improvements in pain and function, indicating how these benefits could be maximised.

Specific suggestions are that rehabilitation programmes could educate people about the causes and potential disease course of osteoarthritis, challenging the belief that exercise causes harm and reassuring people that it is safe and beneficial. The researchers suggest that advice is tailored to each individual patient, managing expectations about the ways in which exercise might improve or worsen their symptoms or leave pain and mobility unchanged.

Physiotherapists already have a role in offering personalised advice and encouragement and this review provides further evidence for them.

Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review

BACKGROUND: Chronic peripheral joint pain due to osteoarthritis (OA) is extremely prevalent and a major cause of physical dysfunction and psychosocial distress. Exercise is recommended to reduce joint pain and improve physical function, but the effect of exercise on psychosocial function (health beliefs, depression, anxiety and quality of life) in this population is unknown.
OBJECTIVES: To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.
SEARCH METHODS: Review authors searched 23 clinical, public health, psychology and social care databases and 25 other relevant resources including trials registers up to March 2016. We checked reference lists of included studies for relevant studies. We contacted key experts about unpublished studies.
SELECTION CRITERIA: To be included in the quantitative synthesis, studies had to be randomised controlled trials of land- or water-based exercise programmes compared with a control group consisting of no treatment or non-exercise intervention (such as medication, patient education) that measured either pain or function and at least one psychosocial outcome (self-efficacy, depression, anxiety, quality of life). Participants had to be aged 45 years or older, with a clinical diagnosis of OA (as defined by the study) or self-reported chronic hip or knee (or both) pain (defined as more than six months' duration).To be included in the qualitative synthesis, studies had to have reported people's opinions and experiences of exercise-based programmes (e.g. their views, understanding, experiences and beliefs about the utility of exercise in the management of chronic pain/OA).
DATA COLLECTION AND ANALYSIS: We used standard methodology recommended by Cochrane for the quantitative analysis. For the qualitative analysis, we extracted verbatim quotes from study participants and synthesised studies of patients' views using framework synthesis. We then conducted an integrative review, synthesising the quantitative and qualitative data together.
MAIN RESULTS: Twenty-one trials (2372 participants) met the inclusion criteria for quantitative synthesis. There were large variations in the exercise programme's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Comparator groups were varied and included normal care; education; and attention controls such as home visits, sham gel and wait list controls. Risk of bias was high in one and unclear risk in five studies regarding the randomisation process, high for 11 studies regarding allocation concealment, high for all 21 studies regarding blinding, and high for three studies and unclear for five studies regarding attrition. Studies did not provide information on adverse effects.There was moderate quality evidence that exercise reduced pain by an absolute percent reduction of 6% (95% confidence interval (CI) -9% to -4%, (9 studies, 1058 participants), equivalent to reducing (improving) pain by 1.25 points from 6.5 to 5.3 on a 0 to 20 scale and moderate quality evidence that exercise improved physical function by an absolute percent of 5.6% (95% CI -7.6% to 2.0%; standardised mean difference (SMD) -0.27, 95% CI -0.37 to -0.17, equivalent to reducing (improving) WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function on a 0 to 100 scale from 49.9 to 44.3) (13 studies, 1599 participants)). Self-efficacy was increased by an absolute percent of 1.66% (95% CI 1.08% to 2.20%), although evidence was low quality (SMD 0.46, 95% CI 0.34 to 0.58, equivalent to improving the ExBeliefs score on a 17 to 85 scale from 64.3 to 65.4), with small benefits for depression from moderate quality evidence indicating an absolute percent reduction of 2.4% (95% CI -0.47% to 0.5%) (SMD -0.16, 95% CI -0.29 to -0.02, equivalent to improving depression measured using HADS (Hospital Anxiety and Depression Scale) on a 0 to 21 scale from 3.5 to 3.0) but no clinically or statistically significant effect on anxiety (SMD -0.11, 95% CI -0.26 to 0.05, 2% absolute improvement, 95% CI -5% to 1% equivalent to improving HADS anxiety on a 0 to 21 scale from 5.8 to 5.4; moderate quality evidence). Five studies measured the effect of exercise on health-related quality of life using the 36-item Short Form (SF-36) with statistically significant benefits for social function, increasing it by an absolute percent of 7.9% (95% CI 4.1% to 11.6%), equivalent to increasing SF-36 social function on a 0 to 100 scale from 73.6 to 81.5, although the evidence was low quality. Evidence was downgraded due to heterogeneity of measures, limitations with blinding and lack of detail regarding interventions. For 20/21 studies, there was a high risk of bias with blinding as participants self-reported and were not blinded to their participation in an exercise intervention.Twelve studies (with 6 to 29 participants) met inclusion criteria for qualitative synthesis. Their methodological rigour and quality was generally good. From the patients' perspectives, ways to improve the delivery of exercise interventions included: provide better information and advice about the safety and value of exercise; provide exercise tailored to individual's preferences, abilities and needs; challenge inappropriate health beliefs and provide better support.An integrative review, which compared the findings from quantitative trials with low risk of bias and the implications derived from the high-quality studies in the qualitative synthesis, confirmed the importance of these implications. AUTHORS' CONCLUSIONS: Chronic hip and knee pain affects all domains of people's lives. People's beliefs about chronic pain shape their attitudes and behaviours about how to manage their pain. People are confused about the cause of their pain, and bewildered by its variability and randomness. Without adequate information and advice from healthcare professionals, people do not know what they should and should not do, and, as a consequence, avoid activity for fear of causing harm. Participation in exercise programmes may slightly improve physical function, depression and pain. It may slightly improve self-efficacy and social function, although there is probably little or no difference in anxiety. Providing reassurance and clear advice about the value of exercise in controlling symptoms, and opportunities to participate in exercise programmes that people regard as enjoyable and relevant, may encourage greater exercise participation, which brings a range of health benefits to a large population of people.

Expert commentary

Hip and knee pain can be reduced, and function improved through exercise, as shown in this analysis of 21 trials, but people tend to instinctively avoid activity for fear of causing harm.

Qualitative research shows that exercise needs to be tailored to individual preferences and abilities along with advice about safety and value to achieve greater participation. This is a message that exercise professionals and the leisure industry need to heed and provide appropriate programmes to enable greater participation in exercise by the less fit and able.

Expert commentary

We live in a world where technology allows ever increasing availability of information yet we know that many struggle with low health literacy.

This review highlights the importance for clinicians, public health and national charities and the need to work together to bridge the gap and maximise the opportunities and appreciate the complex motivations to support people to take part in physical activity.

Even though the review showed only a slight improvement in physical function, depression and pain, this still represents a scalable shift that would benefit the quality of life for many people with arthritis.

Liz Lawrence, Head of Health Service Improvement, Arthritis Research UK